Basic Care Wound Care Diabetic Care Incontinence Care

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. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care Clinical

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care Clinical Nutrition 3 Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 1/61 B|BRAUN OPM . Nutrition Care . Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care Indications for Enteral Nutrition The patient Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 2/61 • is not able to eat • is not allowed to eat • refuses to eat B|BRAUN OPM . Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Indications of Enteral Nutrition Indications Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 3/61 • mechanical obstructions • inadequate food-intake • maldigestion / malabsorption • inflammatory processes • neurogenic disorders • trauma / sepsis • drug / radiation therapy • chronic diseases • preoperative and postoperative conditions B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Indication: Maldigestion Insufficiency of the exocrine pancreas · chronic pancreatitis · pancreatic cancer · pancreatic resection · mucoviscidosis (= cystic fibrosis) Lack of bile acid · reduced production · advanced hepatic cirrhosis · flow impairments: stenosis, gallstones, tumor Lack of intestinal digestive enzymes · lactase · other disaccharidases · peptidases Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 4/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Indication: Malabsorption · intestinal resection · Crohn´s disease/ulcerative colitis · diarrhea • sprue = celiac disease · disturbed intestinal perfusion · disturbed lymph flow · drugs Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 5/61 B|BRAUN OPM Malabsorption .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Contraindications absolute contraindications relative contraindications • shock of any genesis • acute pancreatitis • metabolic disorders - acute metabolic acidosis • paralytic ileus (minimal nutrition possible) - acute serious hypoxia • high reflux-rate (minimal nutrition possible) - acute serious respiratory insufficiency • acute abdomen - acute gastrointestinal bleeding • uncontrolled vomiting • persisting diarrhea - mechanical ileus Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 6/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Dietary Foods for Special Medical Purposes (FSMP) . Standard nutrient formulations or nutrient-adapted formulations for exclusive or partial feeding (1999/21/EG) Nutritionally Complete diet Nutritionally incomplete diet specific for a disease suitable as sole source of nourishment not suitable as the sole source of nourishment Nutrient-defined diet (NDD) Chemically-defined diet (CDD) diet containing main nutrients (carbohydrates, fats, proteins) in their naturally occuring form diet containing main nutrients completely or partly hydrolyzed Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 7/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Characteristics of FSMP „Category of foods for particular nutritional uses specially processed formulated and intended for the dietary management of patients and to be used under medical supervision. “ (1999/21/EG) • energy density (kcal/m. L) • energy ratio (protein : fat : carbohydrates) • balance of minerals, trace elements and vitamines • standard nutrient formulation or nutrient-adapted formulation specific for a disease • defined source of raw materials Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 8/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Osmolarity Osmolality Osmolarity: m. Osm/L = number of osmotically active particles per liter solution (point of reference: volume) Osmolality: m. Osm/kg = number of osmotically active particles per kg solution (point of reference: weight) Osmolality of blood plasma: 285 -295 m. Osm/kg Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 9/61 B|BRAUN OPM Nutrition Care . Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Standard Diets • high-molecular / high-polymeric (NDD) • dietary ratio corresponding to the recommendations • with / without dietary fibers • close to physiologic osmolarity adequate for patients with normal digestion and metabolism Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 10/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Disease Specific Diets indication modification high energy need, fluid restriction high caloric diabetes mellitus starch, glucose substitutes, partly fat modified, rich in dietary fibers respiratory insufficiency, stress metabolism high lipid formulations maldigestion, malabsorption MCT content hepatic insufficiency, stress metabolism impaired immune functions Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 11/61 defined combination of fatty acids (relation of 3 : 6 : 9 fatty acids) B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Disease Specific Diets indication modification protein malnutrition, catabolism protein rich nephrology, pediatrics low protein hepatic insufficiency addition of branched chain amino acids special nutrition for fast proliferating cells (enterocytes, lymphocytes) high glutamine content addition of arginine and RNA disturbed wound healing, impaired immune functions Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 12/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Advantages of an Early Enteral Nutrition • preserving the functions of the gut associated lymphatic tissue • maintaining the barrier of the intestinal mucosa • prevention of villous atrophy by endoluminal substrate induction and improved perfusion in the splanchnic area • reduction of the pathological bacterial flora • improved prophylaxis against infections and sepsis • improved wound healing • stimulation of gastrointestinal hormones • early triggering of the intestinal motility • reduced loss of nitrogen (= loss of muscular tissue = loss of body weight) • prophylaxis against gastric / intestinal ulcers Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 13/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Prophylaxis of Ulcers by Enteral Nutrition Gastric stress ulcers are typical intensive care complications Etiology • increased gastric acidification • reduced protective function of the mucosa Therapy • ulcer prophylaxis by antacids and H 2 -blocker intestinal bacterial flora overgrowth nosocomial pneumonia • ulcer prophylaxis by enteral nutrition physiological regulation of acid output stimulation of protective mechanisms continuous administration is more effective than bolus injection Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 14/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Enteral Routes • oral • nasogastral, nasoduodenal, nasojejunal short-term tube feeding • percutaneous endoscopically controlled gastrostomy (PEG) long-term tube feeding • fine needle catheter-jejunostomy (FNCJ) postoperative tube feeding Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 15/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care Feeding-Tube

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care Feeding-Tube Positions Transnasal Feeding Tubes 1. nasointestinal feeding tube 2. nasogastric feeding tube 1 Percutaneous Feeding Tubes 3. PEG 4. PEG with intestinal transfer tube 5. button 6. PEJ 7. FNCJ Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 16/61 B|BRAUN OPM . Nutrition Care . Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care Gastric Tube Feeding Requirements · normal gastric emptying • adequate protective reflexes • weak / missing protective reflexes Contraindications · dysphagia of neurologic genesis · hiatal hernia (displacement of stomach) · reflux esophagitis Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 17/61 B|BRAUN OPM . Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care Advantages of Gastric Nutrition · gastric reservoir function tolerance concerning quantity and osmolarity controlled nutrient passage into small intestine · bactericide effects of gastric acid · buffering of gastric acid by food Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 18/61 B|BRAUN OPM . Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Duodenal / Jejunal Tube Feeding Indications · disturbed gastric emptying · gastric resection · reflux · vomiting · early postoperative diet Requirements • obligatory continuous administration (by pump): maximum 150 ml/h • endoscopic or radiological position control Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 19/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Diameter and Length of Feeding Tubes · out-side diameter 5 – 32 FR (1 F =1/3 mm) · most frequently used: 8 – 15 FR · the smaller the diameter, the more convenient for the patient (function of the esophageal sphincter remains preserved) · in case of gravity administration 12 FR · 8 FR mostly in case of pump administration · 40 -250 cm length, with marks for x-ray control of position F = French (or Charriere) Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 20/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Material of Feeding Tube PVC feeding tubes (polyvinylchloride) • only for short-term use, daily change necessary · dissolving of the softener, material is becoming hard and cracking · decreased function of the esophageal sphincter through rigid material reflux of stomach contents Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 21/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Material of Feeding Tubes PUR feeding tubes (polyurethane) • soft, flexible, no softener • little wall thickness • long term placement Silicone feeding tubes • long term placement • flexible without softener • in comparison to PUR feeding tubes: thick tube walls are necessary to guarantee stability, as a consequence the out-side diameter increases Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 22/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Placement of Feeding Tubes Nasogastral: • local anesthesia of the nose • introduction as far as pharyngeal space, use of lubricant may be necessary • support of the esophageal passage by swallowing • slow introduction into the stomach Control of position: • aspirate changes colour of p. H-test paper into red (acidic reaction of gastric acid) • insufflation and ausculation (administration of air into the feeding tube by a syringe) typical feeding tube • optional: x-ray control Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 23/61 B|BRAUN OPM

. Basic Care. Wound Care. . Diabetic Care Incontinence Care . Infusion Care .

. Basic Care. Wound Care. . Diabetic Care Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Placement of Feeding Tubes Nasoduodenal: • careful transpyloric introduction of feeding tube into the small intestine Position control: • endoscopic placement and control x-ray control Alternative method: • seldinger technique (placement over an endoscopically positioned guide wire) Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 24/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care PEG Feeding Tubes • long-term enteral nutrition in case of Indications – cachexia – dysphagia – tumors in the head-neck area – multiple trauma – surgery • gastric decompression and drainage Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 25/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care PEG Feeding Tube • Lack of diaphanoscopy • general disorders of wound healing and blood coagulation • peritonitis/peritoneal carcinosis Contraindications • acute pancreatitis • pathological alterations of the gastric wall • ileus • sepsis • relative: Crohn´s disease and ascites • missing agreement of the patient Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 26/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Introduction of PEG („Keymling Method“) · introduction of the gastroscope, air insufflation, determination of the puncture site by diaphanoscopy (fig. 1) · disinfection and anesthesia of the puncture site, advance puncture cannula into stomach under endoscopic control (fig. 2) · removal of the puncture needle, introduction of the thread into plastic cannula (fig. 3) · removal of the guide-thread by endoscope forceps (fig. 3) · fixation of the tube to guide thread by double knot (fig. 4) · retraction of the thread until the silicone disc of the tube stops at inner gastric wall (fig. 5) B|BRAUN · fixation of plate, introduction of the clamp and the luer-lock connector (fig. 6) OPM Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 27/61 .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Introduction of PEG according to Keymling diaphanosco py double knot fixation fig. 1 fig. 4 puncture tube placement fig. 2 fig. 5 externa l fixation guide thread insertion fig. 6 fig. 3 Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 28/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . PEG Complications most common complications: — local wound infections — disturbed microcirculation in case of strong tension between inner and outer fixation plate rare complications: — necrosis and ingrown fixation plate — peritonitis — heavy bleeding because of vascular lesion during puncture Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 29/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Wound Dressing for PEG Feeding Tubes • slit and fleece compresses, fixation fleece • initially daily change, later once or twice a week • skin disinfection • loose fixation of the external fixation plate • daily rotation of the tube after ~ 14 days: formation of a stable fibrous channel Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 30/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . J-PEG tubes • placement of a intestinal tube (9 FR) through the already indwelling PEG tube 15 FR • assumption of the placement of a J-PEG tube – size of the lumen of the placed PEG tube: at least 15 FR – possibility of the navigation of the intestinal tube through pyloric and duodenal stenoses Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 31/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . J-PEG tubes • long-term intestinal feeding with simultaneous gastric in patients with – lossdecompression of consciousness – gastric outflow obstruction Indications – neurological dysphagia with risk of aspiration – pyloric and duodenal stenoses which can still be navigated by the intestinal tube – pancreatitis Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 32/61 – hiatal hernias • enteral nutrition during the early postoperative phase • intestinal recycling of bile with simultaneous gastric B|BRAUN feeding OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care J-PEG tubes • lack of patient consent Contraindications • Peritonitis / peritoneal carcinoma • mechanical Ileus distal to a jejunal tube • generalized disorders of coagulation Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 33/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Introduction of the J-PEG • removal of the Luer-Lock connector of the already placed PEG tube. Fixation of the Y-adapter (fig. 1 / 2) • placement of the intestinal tube via the intestinal leg („i“, green) (fig. 3) • Shortening of the intestinal tube and connection with the positive/negative Luer-Lock connector (fig. 4) • Connection of the tube with the Y-adapter of the PEG tube (fig. 4) • radiological checking of the tube position (or sonographic) Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 34/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care Introduction

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care Introduction of the J-PEG Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 35/61 B|BRAUN OPM . Nutrition Care . Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care complications of the J-PEG tube • most comon complications: - dislocation of the intestinal tube - gastric loop formation - local wound infections related to the PEG further complications cf. PEG tube Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 36/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Fine Needle-Catheter Jejunostomy (FNCJ) • postoperative enteral nutrition: – after open gastrointestinal surgery – for patients with multiple trauma Indications • long-term nutrition, if introduction of PEG is impossible Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 37/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Fine needle-catheter jejunostomy (FNCJ) • chronic and acute inflammation of the small and large intestine • mechanical ileus Contraindications • peritonitis • acute pancreatitis • missing aggreement of the patient Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 38/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Introduction of FNCJ Principle of the method A fine needle-catheter jejunostomy is carried out during surgical interventions (laparotomy). • puncture of abdominal wall (fig. 1) • splitting and withdrawal of puncture needle (fig. 2) • puncture of jejunum and channeling (fig. 3) • fixation of tube (fig. 4) Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 39/61 B|BRAUN OPM Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care Introduction

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care Introduction of FNCJ puncture of abdominal wall splitting of puncture needle Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 40/61 puncture of jejunum fixation B|BRAUN OPM . Nutrition Care . Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Ways of Enteral Feeding nutrient-intake intermittent feeding 200 - 400 m. L in 30 - 60 minutes - by gravity - by pump Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 41/61 continuous feeding low flow rates bolus fast injection of 250 -500 m. L - by syringe - by pump B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Application Systems Connection with nutrient container • administration set with bottle-connection (screw cap / crown cork) • storage-bag with integrated set • spike application systems Connection with feeding tubes: • luer-lock • funnel / cone • luer-plug Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 42/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care Application Systems storage-bag bottle-connection Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 43/61 B|BRAUN OPM . Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . General requirements for a feeding-pump • small, light and handy • easy handling • easy setting and cleaning • easy introduction of the pump segments • quiet • operation by rechargeable battery • bag for mobile use • easy error analysis Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 44/61 · acoustic und optic alarm in case of - occlusion - air in the application system - end of administration (volume, time) - low battery capacity - disorder of the equipment B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Indications for Pump-Controlled Enteral Nutrition • slow and controlled start of enteral nutrition • early postoperative feeding • intestinal administration (obligatory) • pediatric enteral nutrition • gastrointestinal complications (disorders of gastric emptying, diarrhea, vomiting, etc. ) • impaired digestion (for example: progressive tumors) • metabolic disorders (for example: complications in diabetes mellitus) • prophylaxis of aspiration (individual decision) Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 45/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Patient Monitoring diagnosis and problems of the tube feeding diet and patient way of administration Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 46/61 B|BRAUN OPM requirements of the patient: - energy, - nutrients, - liquid

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Patient Monitoring Start of tube feeding correct tube position control: x-ray, aspiration of gastric fluid (p. H control), air insufflation adequate gastric emptying (control of aspirate volume) adequate protective reflexes skin and wound control Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 47/61 B|BRAUN OPM Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Patient Care elevated head of the patients bed (30 -45 degrees) temperature of tube feeding: room temperature rinsing of the feeding tube before and after feeding and medication define and control feeding time initially low dose / low rate correct medication (nutrient-drug-interactions) daily change of the application systems care of mouth and nose, stimulation of salivary secretion change of wound care kits keeping hygiene standard Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 48/61 B|BRAUN OPM Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Liquid Application to cover liquid needs (taking the liquid-content of food into account) to rinse the feeding tube adequate • fresh tap water (if quality is adequate) • mineral water without gas inadequate • black tea discolouring of the tube • beverages with gas or fruit acids (for example: coke, juice, fruit tea) tube clogging, sedimentations, flatulenc ! In case of giving tea or preboiled water: do not leave vessel open, cool down covered, use fresh tea / water daily! Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 49/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Rinsing of the Tube Rinse according to the length of the feeding tube by using 40 - 60 ml liquid (use 20 ml syringe) • before start of tube feeding • in case of interruption • during continuous supply: every 4 -8 hours • after termination of tube feeding • before medication • after medication • in case of unused tube: once a day Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 50/61 B|BRAUN OPM Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Enteral Medication • Rinse tube thoroughly before and after each medication • do not give drugs together with enteral diets incompatibility ! • prefer fluid drugs complete dissolving of capsula and tablets • dilute with enough water high osmolarity of drugs • attention to carrier substances diarrhea, electrolyte shifts (example: sorbitol-containing drugs like paracetamoljuice) Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 51/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Medication during Tube Feeding Is oral application possible? yes no alternative routes of application: rectal, transdermal, sublingual, subcutaneous, i. m. , i. v. Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 52/61 enteral applicaton through feeding tube (if possible: liquids) B|BRAUN OPM oral application .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Medication through Feeding Tubes Type and position of feeding tubes are crucial for administration and effect of the drug. • in-side diameter application of the drug • position of feeding tube diluting processes • gastric position p. H 1, 5 • duodenal position p. H 8 Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 53/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Monitoring of Enteral Medication serum-level of the drug clinical effect on the intestinal motility, diarrhea side effects: e. g. diarrhea incompatibility: interaction between drug and tube feeding diet Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 54/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care Enteral

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care Enteral Start-Regime Total volume: 2500 m. L/day Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 55/61 B|BRAUN OPM . Nutrition Care . Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Gastric Emptying Regulation: Fluid-emptying: Particle-emptying: Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 56/61 · hormone-regulated · reflex-mediated (N. Vagus) · by chemoreceptors of the small intestine pressure difference between stomach and duodenum · < 2 mm · bigger particles are hold back by retropulsion, emptying during interdigestive stage B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Time of Gastric Emptying gastric contents emptying time high neutral, hypoosmolar, proteins, carbohydrates emptying time low Lipids, hyperosmolar , acidic Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 57/61 B|BRAUN OPM Nutrition Care . Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Gastric Emptying transitory disorders of gastric emptying: chronic retardation of gastric emptying: Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 58/61 • • • after surgery / anaesthesia viral gastroenteritis hyperglycemia hypothyreosis opiates, anticholinergica, -adrenergic substances, nicotine • functional dyspepsia • diabetes mellitus • stage after vagotomy • anorexia nervosa • sklerodermia • dermatomyositis • neoplasia of the stomach • idiopathic (as an independent clinical picture) B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Gastrointestinal Motility after Surgery Begin of function depends on alimentary stimulation Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 59/61 stomac h 32 -72 hours after surgery small intestine 8 -12 hours after surgery colon 32 -72 hours after surgery B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Control of gastric emptying after surgery or trauma Aspiration of gastric contents aspirate volume after tube feeding < 150 ml > 150 ml aspirate back into the stomach continue tube feeding aspirate back into the stomach interruption for 1 hour continue tube feeding aspirate volume after 2 hours < 150 ml > 150 ml aspirate back into the stomach continue tube feeding 150 ml aspirate into the stomach interruption for 1 hour reduce flow rate of supply new control after 2 hours Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 60/61 B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Complications in Enteral Nutrition • mechanical complications • gastrointestinal complications Complications: • metabolic complications • infectious complications Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 61/61 B|BRAUN OPM Stoma Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Complications mechanical metabolic • dislocation of the tube • hyperglycemia • electrolyte shifts • dehydration (= tube feeding syndrome) • overhydration ( heart failure) • obstruction of the tube • esophagitis gastrointestinal infectious complications • diarrhea • wound infection • flatulence • aspiration pneumonia • nausea • peritonitis Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 62/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Aspiration Pneumonia gastric esophageal reflux of gastric contents into the respiratory tract • actively by vomiting • passively by regurgitation Etiology • reduced or missing protective reflexes and function of gastric sphincter in case of unconscious or anesthetized patients • ileus • gastrointestinal bleeding • high secretion Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 63/61 • increased gastric and intraabdominal pressure because of - disturbed gastric emptying - pregnancy - drugs (succinylcholine) - intraabdominal lesions · nasogastric tube as cause of reflux B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Aspiration Prophylaxis ! Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 64/61 control of protective reflexes during enteral feeding: elevation of the head of the patient’s bed (30 - 45 degrees) control of gastric emptying B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Gastrointestinal Complications - Diarrhea • food intolerance, allergy • drugs • tube feeding diet (osmolarity of 250 to 500 m. Osm/L does not cause diarrhea) • temperature of food • infection • colon-atrophy • chemo-/ radiation therapy Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 65/61 reduction and avoidance of related nutrients reduction of osmolarity control of side effects dietary fibers, MCT-content mono-, disaccharides rate of supply, concentration room temperature clarification of etiology, iatric intervention control of hygiene standard preparations of intestinal bacteria special enteral diets flow rate special diets B|BRAUN OPM .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care . Gastrointestinal Complications constipation, flatulence, diarrhea nausea, vomiting, diarrhea control of side effects adjusting diet to room temperature increase liquid supply control of gastric emptyin (important in case of diabetes mellitus) supply of dietary fibers reduce flow rate and concentration in case of intolerance reaction / allergy: reduce or avoid related nutrients control side effects of drugs, reduce osmolarity reduce flow rate and concentration treatment of gastritis and infections in case of steatorrhea: MCT-rich diet Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 66/61 B|BRAUN OPM

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care .

. Basic Care. Wound Care. Diabetic Care . Incontinence Care . Infusion Care . Nutrition Care . Stoma Care Documentation of Enteral Nutrition position of feeding tube skin alterations quantity and quality of diet (calculated actual deviation) administration time / flow rate feces: quantity, consistency, colour, frequency urine: quantity, abnormity drugs complications Enteral Nutrition Clin. Nutr 3/ OPM Germany/Stand 02 2002 -08 -01 page 67/61 B|BRAUN OPM .